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Techniques in Valve-in-Valve TAVR Vinod H. Thourani, MD Professor of Surgery and Medicine Chief of Cardiothoracic Surgery, Emory Hospital Midtown Co-Director:

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Presentation on theme: "Techniques in Valve-in-Valve TAVR Vinod H. Thourani, MD Professor of Surgery and Medicine Chief of Cardiothoracic Surgery, Emory Hospital Midtown Co-Director:"— Presentation transcript:

1 Techniques in Valve-in-Valve TAVR Vinod H. Thourani, MD Professor of Surgery and Medicine Chief of Cardiothoracic Surgery, Emory Hospital Midtown Co-Director: Structural Heart and Valve Center Emory University School of Medicine AATS April 2015

2 Disclosures Edwards Lifesciences –Research, consulting St. Jude Medical –Research, consulting Boston Scientific –Research Medtronic –Research Jenavalve –Research Abbott Medical –Research, consulting Apica Cardiovascular –IP, co-founder

3 Bioprosthetic Valves Dvir D et al: JAMA 312:162-170, 2014

4 The Valve-in-Valve App Ideal positioning with 15% of XT stent below lowest visible margin of Perimount stent. The 23 mm XT stent is 14 mm tall at nominal diameter (shorter than the Perimount stent, which is 15 mm tall).

5 Main issues Aortic-valve-in-valve procedures Malpositioning Ostial coronary occlusion Residual stenosis

6 Device Malpositioning P= 0.04 StentlessStented- Mosaic Stented- Non-Mosaic Dvir D et al: JAMA 312:162-170, 2014

7 Stented (n=441) Stentless (n=112) P Aortic regurgitation ≥+2 (%)4.68.40.28 Aortic valve area (cm2)1.42 ± 0.431.73 ± 0.670.003 Aortic valve max gradient (mmHg)30.4 ± 14.322 ± 11.9<0.001 Aortic valve mean gradient (mmHg) 16.9 ± 911.7 ± 7<0.001 LVEF (%)52.1 ± 11.449.3 ± 12.20.047 Post procedure Echo Results Dvir D et al: JAMA 312:162-170, 2014

8 VIVID Registry 1-Yr Outcomes All (n=459) Stenosis (n=181) Regurg (n=139) Combined (n=139) P Death, #, % 62 (16.8) 34 (23.4) 10 (8.8) 18 (16.1) 0.01 NYHA FC I/II I/II 163 (86.2) 62 (84.9) 46 (85.2) 55 (88.7) 0.34 III/IV III/IV 26 (13.8) 11 (15.1) 8 (14.8) 7 (11.3) 0.34 AVA, mean (SD), cm 2 1.38 (0.42) 1.28 (0.29) 1.51 (0.48) 1.36 (0.45) 0.01 AV max grad, mean (SD), mmHg 30 (14.7) 32.3 (14.9) 25.2 (15.4) 32.1 (12.5) 0.005 AV mean grad, mean (SD), mmHg 16.9 (9.1) 18.3 (9.5) 13.8 (8.9) 18.4 (8) 0.001 30% AR Dvir D et al: JAMA 312:162-170, 2014

9 Patient LW 83 YO F with severe stenosis of a 21 mm Edwards Perimount bioprosthetic AoV (1999) and NYHA IV heart failure symptoms. Height 152 cm Weight 60 kg Creatinine 0.77 mg/dL – Ovarian CA on active chemo – Paroxysmal AF on warfarin – Dyslipidemia/HTN – Hypothyroidism – Moderate COPD: FEV1 = 0.95 L (60 %) – LVEF 60 % Proposed Comm TF V-in-V STS 15%

10 Patient LW LVOT 20.2 mm AVA 0.51 cm 2

11 Patient LW

12 RCALCA

13 LAO 19, caudal 10 Patient LW

14 May need glide wire May need to pace

15 Patient LW

16

17

18 Conclusions The field of valve-in-valve for failed surgically placed bioprosthesis is expected to increase The proper configuration for placement of the TAVR valve remains controversial Long-term results for this procedure are not known The standard of care remains surgical redo valve replacement in low-, and medium-risk and some high-risk patients

19 Thank you. Vinod H. Thourani, MD vthoura@emory.edu

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